“Acute flaccid myelitis (AFM) is not nationally notifiable; CDC relies on clinician recognition and health department reporting of patients under investigation (PUIs) for AFM to learn more about AFM and what causes it.”

But could there be more cases?

The Case for Making AFM Reporting Mandatory

Although AFM isn’t yet a nationally notifiable disease, 120 other diseases are, from Anthrax and Botulism to Vibriosis and Zika virus disease.

The Nationally Notifiable Condition List depends on state laws for any mandate to report.

Who picks them?

The Council of State and Territorial Epidemiologists.

“Although AFP surveillance is commonly conducted in many countries currently still at risk for ongoing transmission of poliovirus, AFP is not a reportable condition in any U.S. state and routine surveillance and assessment for AFP is not performed. Therefore, understanding the baseline incidence and epidemiology of AFM and its public health impact in the United States is significantly limited.”

Revision to the Standardized Surveillance and Case Definition for Acute Flaccid Myelitis

Utilize standardized criteria for case identification and classification for acute flaccid myelitis (AFM) but do not add AFM to the Nationally Notifiable Condition List . If requested by CDC, jurisdictions (e.g. States and Territories) conducting surveillance according to these methods may submit case information to CDC.

Report cases as soon as possible and continue surveillance.

Share data to “measure the burden of acute flaccid myelitis (AFM).”

And the CDC has agreed.

“CDC concurs with this position statement. We look forward to continuing to work with our jurisdictional partners to address this important public health issue. This standardized case definition provides an opportunity to better define the spectrum of illness seen with AFM and to determine baseline rates of AFM in the United States. During review of the position statement, a few minor edits were identified as necessary for clarification, and we are working with the author to make these changes.”

What would be the difference if AFM was added to the Nationally Notifiable Condition List?

For one thing, because the list of reportable conditions varies from state to state, it would provide a uniform case surveillance and case definition.

But we already have that in the CSTE Position Statement on Acute Flaccid Myelitis.

The big issue is that there is no federal law that actually mandates reporting for the diseases on the list! Or even to report them to the CDC.

“Each state has laws requiring certain diseases be reported at the state level, but it is voluntary for states to provide information or notifications to CDC at the federal level.”

CDC on Data Collection and Reporting

It is up to state laws – in each and every state.

“The legal basis for disease reporting is found at the state level, where inconsistent laws may differ in terms of which conditions are reportable and their reporting process.”

Brian Labus on Differences In Disease Reporting: An Analysis Of State Reportable Conditions And Their Relationship To The Nationally Notifiable Conditions List

So even if the Council of State and Territorial Epidemiologists added AFM to the Nationally Notifiable Condition List, you would then need each state to pass a law adding AFM to their lists of notifiable diseases.

“Currently AFM is not a reportable condition in Texas.”

TxDSHS on Acute Flaccid Myelitis

How long would that take?

Zika is on the Nationally Notifiable Condition List, but guess what, like AFM, it isn’t on the reportable condition list in many states…

Utah, Washington and Colorado have already added AFM to their list of notifiable conditions. Has your state?

Want to get more cases of AFM reported to the CDC?

Let’s raise awareness about AFM and educate parents and health professionals to get all cases diagnosed, as they can then get reported to local and state health departments, who will then report them to the CDC.

Making AFM reporting mandatory might sound like a big deal, but will it really make any difference in getting kids diagnosed and treated?

“Ultimately, we would have to decide what the purpose of making something nationally notifiable is. We can investigate it just as well without that designation, and keeping things at the state level (for now) allows a lot more flexibility in how we define and investigate it. It might seem frustrating because it isn’t on the nationally-notifiable list, but that honestly doesn’t matter in terms of how we investigate things.”

Brian Labus, PhD, MPH

Cases still get investigated without being on the Nationally Notifiable Condition List.

Cases still get reported without being on the Nationally Notifiable Condition List.

And that’s good, because adding AFM to the Nationally Notifiable Condition List is not something that would happen overnight.

CP-CRE was added to the National Notifiable Condition List in 2018 at the 2017 CSTE annual meeting.

The CSTE would probably discuss it at their next meeting (next summer), and if approved, it would take effect at the beginning of the new year – January 2020. But then, then CDC has to get approval from the Office of Management and Budget (OMB) to actually get permission to start collecting the data on AFM for the Nationally Notifiable Condition List. All of that likely means that the earliest we would see “national” reporting for AFM would be sometime in 2022.

Does that mean we should jump on it now if it is going to take so long, or should we wait to figure out a definitive cause, and then put that on the Nationally Notifiable Condition List?

Whatever we do, remember that it still wouldn’t be mandated reporting unless each and every state actually passes a law mandating reporting of AFM cases to the CDC. Again, being on the Nationally Notifiable Condition List simply means that states are strongly encouraged to report their cases, as they do now. There are several diseases on the Nationally Notifiable Condition List that states never add to their own notifiable conditions list.

“It is voluntary that notifiable disease cases be reported to CDC by state and territorial jurisdictions (without direct personal identifiers) for nationwide aggregation and monitoring of disease data. Regular, frequent, timely information on individual cases is considered necessary to monitor disease trends, identify populations or geographic areas at high risk, formulate and assess prevention and control strategies, and formulate public health policies. The list of notifiable diseases varies over time and by state. The list of national notifiable diseases is reviewed and modified annually by the CSTE and CDC. Every national notifiable disease is not necessarily reportable in each state. In addition, not every state reportable condition is national notifiable.”

CDC on Data Collection and Reporting

Mostly, folks should understand that simply being on the Nationally Notifiable Condition List may not mean as much as they think it does.

“Although disease and condition reporting is mandated at the state, territory, and local levels by legislation or regulation, state and territory notification to CDC is voluntary. All U.S. state health departments, five territorial health departments, and two local health departments (New York City and District of Columbia) voluntarily notify CDC about national notifiable diseases and conditions that are reportable in their jurisdictions; the data in the case notifications that CDC receives are collected by staff working on reportable disease and condition surveillance systems in local, state, and territorial health departments.”

CDC on Data Collection and Reporting

And that epidemiologists at the local, state, and national level are working hard to identify all cases of AFM, which will hopefully help them figure out what is causing these cases, how to treat kids who are already affected, and how to prevent new cases.

They are identifying more and more cases of AFM even though few states have mandatory reporting, AFM isn’t on the Nationally Notifiable Condition List, and reporting of cases to the CDC is voluntary.

Mosquito bites aren’t good, but you usually don’t have to get panicked about them.

Depending on where you live, a mosquito bite can be just a nuisance or it can lead to a life-threatening disease. From Chikungunya virus to Zika, most parents have learned to fear mosquito-borne diseases and because they hear about them so much, fear or even get panicked over mosquito bites.

While it is good to prepared and learn to avoid mosquito bites, you likely shouldn’t be panicked.

But even if your kids aren’t at risk for a mosquito-borne disease, it’s no fun getting bit by mosquitoes. Mosquito bites are itchy, and even when bites don’t get infected, they can leave behind crusted scabs that kids continue to pick at, over and over again.

Still no reason for panic or fear – just good reasons to learn to avoid mosquito bites.

Mosquitoes and Mosquito-Borne Diseases

Diseases that can be spread from the bite of a mosquito can include:

Chikungunya – can develop fever and severe and debilitating joint pain 3-7 days after a mosquito bite from Aedes aegypti and Aedes albopictus mosquitoes in countries in Africa, Asia, Europe, and the Indian and Pacific Oceans, Caribbean countries, and most recently, in Florida, Puerto Rico, and the U.S. Virgin Islands.

Dengue – can cause severe flu like symptoms, including fever, severe headache, eye pain, joint and muscle pain, rash, and bleeding, after a mosquito bite in one of at least 100 endemic countries, including many popular tourist destinations in Latin America, Southeast Asia and the Pacific islands. While there are cases in the US, it is important to keep in mind that “nearly all dengue cases reported in the 48 continental states were acquired elsewhere by travelers or immigrants.”

Eastern Equine encephalitis – a very rare disease, which is fortunate, as it is one of the most deadly of the mosquito-borne diseases. Transmission is in and around swampy areas, with most cases in Florida, Georgia, Massachusetts, and New Jersey.

Filariasis – spread by repeated mosquito bites over months to years, this disease is still found in at least 73 countries in parts Asia, Africa, the Western Pacific, and parts of the Caribbean and South America, these parasitic worms can grow and live in our lymph system

Japanese encephalitis – you can get a Japanese encephalitis virus infection after being bit by an infected Culex species mosquito in one of 24 countries in South-East Asia and the Western Pacific, especially if you are not vaccinated.

La Crosse encephalitis – rare, but can occur in the upper Midwestern and mid-Atlantic and southeastern states and can cause severe disease, including encephalitis, in children.

Malaria – although malaria was eliminated in the US in the early 1950s, we still see about 1,700 cases each year in returning travelers. That’s because malaria is a still a big problem around the world, from certain some states in Mexico to most of sub-Saharan Africa and South Asia.

St. Louis encephalitis – can occur in eastern and central states, starts with mild symptoms, but can very rarely (between 1 to 12 cases a year) progress to encephalitis (inflammation of the brain).

West Nile – has now been found in every state except Alaska and Hawaii, but up to 80% of people don’t develop any symptoms and only 1% develop severe symptoms, with folks over age 60 years most at risk. Although West Nile season peaks in mid-August, cases are usually reported from late summer through early fall.

Western Equine encephalitis – rare, but deadly, like Eastern Equine encephalitis, and is found in states west of the Mississippi River

Yellow fever – a vaccine-preventable disease, the Yellow fever virus is still found in tropical and subtropical areas in South America and Africa.

Zika – is mostly a risk during pregnancy as it can cause serious birth defects, including microcephaly, so there are warnings to avoid high risk areas, which in addition to multiple countries and territories around the world, includes Brownsville, Texas and previously included Miami-Dade County, Florida

Won’t a long list of diseases get parent’s panicked? Only if they skip the part about where the mosquitoes that cause those diseases are active.

What to Do If a Mosquito Bites Your Child

Do you know what to do if a mosquito bites your child? Photo by James Gathany

If a mosquito bites your child, don’t panic. There is no reason to run to your pediatrician or the ER and get tested for West Nile or Zika.

That’s not to say a mosquito bite couldn’t send you to the ER, but it would likely only be if your child was severely allergic, with the bite causing an anaphylatic reaction. Fortunately, most bites just leave little red bumps that go away in a few days if you don’t scratch them too much.

So the key treatment after a mosquito bite is classically about relieving the symptoms of itching. As with other itchy rashes, you can do this by:

applying an OTC anti-itch cream (hydrocortisone cream or calamine lotion) to the bite

taking an oral antihistamine, especially at night

applying a prescription steroid cream to help control itching

Also, keep your child’s finger nails short to minimize damage from scratching and wash the areas with soap and water to decrease the risk of secondary infections.

“Where you live, your travel history, and the travel history of your sex partner(s) can affect your chances of getting Zika.”

CDC on Know Your Zika Risk

In general, you should see your pediatrician if you have the symptoms of a mosquito-borne disease and have been in an area with risk of that disease.

Should you worry about dengue, West Nile, or Zika, etc?

Does your child live in an area where you can commonly find the mosquitoes that carry any of these diseases?

Did your child recently visit an area where you can commonly find the mosquitoes that carry any of these diseases?

Is your child a pregnant teen?

Is your teen sexually active?

Does your child have a chronic medical condition, such as cancer, diabetes, hypertension, or kidney disease?

Is your child a first- or second-generation immigrant from a malaria-endemic country who returned to their home country to visit friends and relatives?

Was your child at risk for a mosquito-borne disease and skipped taking preventative medications for malaria or skipped getting a Japanese encephalitis vaccine or a Yellow fever vaccine?

Again, see your pediatrician if your child had a mosquito bite and now has the symptoms of a mosquito-borne disease after being in an area with risk of that disease. This is especially important for anyone who is pregnant or with a chronic medical problem, as they might be at higher risk for severe disease. The elderly are more at risk too.

Preventing Mosquito Bites

Of course, whether you are traveling to the tropics or going for a walk in your neighborhood, your best bet is going to be trying to avoid mosquitoes and mosquito bites in the first place.

get rid of standing water around your home – places where mosquitoes can breed

make sure windows and doors have screens or are kept shut to keep mosquitoes out of your home

instead of insect repellent, consider using mosquito netting to cover your infant’s stroller or carrier when outside, and especially when in high risk parts of the world, using insecticide treated bed nets

And review travel advisories before planning a trip to see if you need to take any additional precautions to avoid a mosquito-borne disease.

What to Know About Mosquitoes and Mosquito Bites

Mosquito-borne diseases, like dengue, West Nile, and Zika, can certainly be serious, but you likely don’t need to panic your child has gotten one of them every time he or she gets a mosquito bite.